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Complete the sections below, attach electronic copies of your receipts and click submit for your claim to be processed.
List all prescriptions purchased. Please attach receipts for every expense.
Attach your physician's written recommendation and diagnosis where applicable.
Note: All fields are required except for Dispensing Fee
Note: Touch title area to scroll.
Name of Patient
Relation to Member
Date of Expense
Dispensing Amount Fee
Amount Charged (Drug Cost)
List all services and/or items purchased. Please attach receipts for every expense. Attach your physician's written recommendation and diagnosis where applicable.
Note: All fields are required
Type of Expense
Complete all sections in the form below for each dental procedure. Attach a copy of the dental claim statement provided by your dental office.
Note: All fields are required except for Lab Charge, Tooth Surface and Tooth Code (provide these if available)
Date of Service
Procedure Code(5 digit)
Lab Charge(If applicable)
All of the remaining portion of the claim to be paid
A specific amount $
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